Andropause: Symptoms, Diagnosis, and Evidence-Based Treatment

Andropause — clinically called late-onset hypogonadism or age-related testosterone deficiency — is the gradual decline in testosterone production that begins in most men in their late 30s and progresses at roughly 1–2% per year. Unlike menopause, it is not a distinct event, and not every man becomes symptomatic. Roughly 20% of men over 60 and 30–50% of men over 70 meet the biochemical and symptomatic criteria for treatment consideration.

The condition is real and well-characterized in the endocrinology literature, but it is also over-diagnosed by non-specialty clinics that treat borderline lab values as automatic prescriptions. A careful diagnostic workup separates true hypogonadism from reversible secondary causes.

The most specific symptoms are sexual: reduced morning erections, low libido, and erectile dysfunction. These have the strongest correlation with low testosterone in prospective studies. Less specific — but common — symptoms include fatigue, loss of drive, depressed mood, reduced muscle mass and strength, increased visceral fat, poor concentration, and disturbed sleep.

Because these overlap heavily with depression, sleep apnea, hypothyroidism, and simple deconditioning, symptom checklists alone are insufficient. Diagnosis requires labs.

Step 1: two separate morning (7–10 AM), fasted total testosterone measurements, taken at least a week apart. A single value is not diagnostic due to normal circadian and day-to-day variation.

Step 2: if total testosterone is low or borderline, add free testosterone, SHBG, LH, FSH, prolactin, and estradiol. Elevated LH and FSH with low testosterone suggest primary (testicular) hypogonadism; low or normal LH and FSH suggest secondary (pituitary/hypothalamic) hypogonadism, which requires further workup including prolactin and often pituitary imaging.

Step 3: rule out reversible drivers — obesity, poorly controlled diabetes, obstructive sleep apnea, opioid use, corticosteroids, alcohol, and thyroid disease. Addressing these often restores testosterone without hormonal therapy.

First line for symptomatic men with borderline labs is structured lifestyle intervention: 5–10% body-weight reduction if applicable, resistance training 3–4x per week, sleep-apnea screening and treatment, correction of vitamin D and zinc deficiencies, and alcohol moderation. In studies of obese hypogonadal men, weight loss alone raises total testosterone by 100–200 ng/dL.

Well-formulated over-the-counter support formulas — the ones we cover in our top reviews — provide the micronutrients (zinc, magnesium, vitamin D, ashwagandha) that fill gaps commonly seen on labs. They are not a substitute for TRT in true hypogonadism, but they are a reasonable adjunct to lifestyle for men in the low-normal range.

Testosterone replacement therapy (TRT) is indicated when biochemical hypogonadism plus consistent symptoms persist despite lifestyle correction. TRT is a long-term commitment that requires ongoing monitoring of hematocrit, PSA, estradiol, and cardiovascular risk factors, and is not appropriate for men actively trying to conceive without concurrent fertility protocols.

TRT reliably improves libido, erectile function, mood, energy, lean mass, and bone density in appropriately selected men. It does not reliably improve cognition in men without baseline deficiency, does not treat depression that is not driven by hypogonadism, and does not restore fertility (it typically suppresses it).

Long-term cardiovascular data have been reassuring in the large TRAVERSE trial, but TRT remains a physician-supervised decision with individualized risk-benefit analysis — particularly for men with polycythemia, untreated sleep apnea, or a history of prostate cancer.